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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 04/05/2021
Date Signed: 04/05/2021 09:54:00 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CASA SANDOVALFACILITY NUMBER:
019200922
ADMINISTRATOR:ROSANA FRIASFACILITY TYPE:
740
ADDRESS:1200 RUSSELL WAYTELEPHONE:
(510) 727-1700
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:99CENSUS: 54DATE:
04/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rosana Frias, AdministratorTIME COMPLETED:
09:45 AM
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On 04/05/21 at 9:00AM, Licensing Program Analyst (LPA) conducted a case management tele-visit as a result of the department receiving a self reported incident call from administrator (ADM) on 04/02/21. Due to COVID-19 shelter in place order, ADM was not physically available to sign this report.

ADM called the CCLD desk duty line on 04/02/21 and reported alleged elder abuse wherein a female resident (R1) reported staff (S1) hit her on the left shoulder on 3/21/2021 while providing care in her living room inside her apartment. Another staff (S2) checked on R1 on 4/01/21 and did not observe any mark or bruise on R1.

At 9:15AM, LPA, along with ADM, conducted a tele-visit with R1 inside her apartment. LPA observed R1 was comfortably resting in her bed. LPA asked R1 if she was OK and she said "Yes". LPA observed no marks or bruises on R1. ADM told LPA that S1 who allegedly hit R1 was placed on administrative leave pending an internal investigation. ADM will advise CCL of the outcome of the investigation once complete.

No deficiencies were observed during this tele-visit.

Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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